State of New Jersey Small Business Vendor Registration Form

1-svrs 07/04 (041808-4159)

1-800-533-0186



State of New Jersey Small Business Vendor Registration Form

Print or Type Firm Name ______________________________________________ Mailing Address___________________________________________ City_______________________State___NJ____Zip______________ Provide full address of principal place of business

For Agency Use Only

Approved _____ Date________Int.________ Disapproved___ Date________Int.________

_______________________________________________________

County _________________________________________________ Phone __________________________________________________

Referring Agency: MBE/WBE______NJDOT NJT_____ NY/NJ PA______SBDC_____________

OTHER__________________

Fax Number E-Mail __________________________________________________ Contact Person ___________________________________________ Title ____________________________________________________ Federal ID # _____________________________________________ Social Security # _________________________________________

(Use S.S.# ONLY if you don't have a Federal ID#)

Payment Included Yes

No

Payment Date ____________________

DO NOT WRITE IN THIS SPACE

1-stop registration

ANSWER ALL QUESTIONS

1. Describe the firm's major field(s) of operation.

1a. Please provide the North American Industrial Classification System (NAICS) Code* that best describes your business

2. Please provide your firm's gross revenue

Current Year

Last Year

Previous Year

(If the business has operated for less than three years, provide the gross revenue to the period that the business has operated.)

3. Is this company independently owned and operated whereas the Management owns at least 51% and is responsible for both daily

and long-term operations?

Yes

No

4. Is this company registered to do business in New Jersey?

Yes

No

5. Check all that apply:

o At least 51% of company's current employees work in New Jersey

o At least 51% of this firm's business in conducted in New Jersey

o Total number of full time employees

Yes Yes

No No

6. Is this firm in a construction-related industry?

Yes

No

? If yes, list all construction craft codes (from attached list)

09/10 rev. 2

1

7. For all other non-construction related industries, list all applicable commodity codes (state.nj.us/treasury/purchase/commcode.htm)

Do not leave code boxes blank. Registration cannot be completed unless appropriate codes are provided.

8. Ownership Information

Name of Owner (s)

Sex M/F

# Shares Owned

% Owned % % % % % % % % % %

THIS FORM MUST BE NOTARIZED

I attest that this form has been completed as directed and that the information contained herein is true and accurate to the best of my knowledge. I understand that any information willfully falsified or omitted may result in the firm being disbarred from bidding on State contracts for a period of up to two years and in prosecution under New Jersey's fraud statutes and liability to attendant civil or criminal penalties.

______________________________

Signature of President, Owner or Managing Partner

Title ________________________________________

____________________________________

Printed Name

Date _________ Phone_____________________

Executed for (name of company) _____________________________________________________ Printed Name

Sworn to me this day of ___________ 20____

Notary Public __________________________________________________

Return completed registration form and $100.00 application fee (check or money order) payable to" NJ Commerce" and return to: New Jersey Commerce, Office of Business Services, PO Box 820, Trenton NJ 08625-0820

For information on State Bid Opportunities, please go to and select "Contract Opportunities".

If your business enterprise is not registered with the New Jersey Purchase Bureau to receive state bid announcements for procurements exceeding $25,000, request your Bidder's Mailing List Application from the New Jersey Purchase Bureau by calling

609-984-5396 or download it from their website at state.nj.us/treasury/purchase/forms/forms.htm

*North American Industrial Classification System (NAICS) Codes can be obtained from epcd/www/naics.html

Optional Statistical Data

Based on the following guidelines do you consider your business to be: A sole proprietorship owned and controlled by a minority or woman. A partnership or joint venture owned and controlled by a minority or woman in which at least 51 % of the ownership is held by a minority or woman and the management and daily business operations of which is/are controlled by one or more minorities or women. A Corporation or other business entity authorized under the laws of the United States whose management and daily business operations are controlled by one or more minorities or women who own it, and which is at least 51% owned by minorities women or, if stock is issued, at least 51 % of the stock is owned by one or more minorities or women.

Minority Owned ( Black Hispanic

Asian American Indian )

Women Owned

Dear Small Business Vendor;

The State of New Jersey's Small Business Set-Aside program includes goals that 25% of state contract and purchase order dollars be awarded to Small Business Enterprises (SBE). Small Business Enterprise (SBE) registration will add your company's name to the state listing of vendors eligible to participate in these selected contract offerings.

Standards of Eligibility for "Small Business"

The state small business set-aside program's criteria, set forth in N.J.A.C. 12A:10 (N.J.A.C. 17:13) and N.J.A.C. 12A:10A (N.J.A.C. 17:14) is as follows:

For Goods and Services Contracts under Chapter 10, Small businesses with no more than 100 fulltime employees will be registered in one of the following 3 categories:

i. Small businesses whose gross revenues do not exceed $500,000 ii. Small businesses whose gross revenues do not exceed $5 million iii. Small businesses whose gross revenues do not exceed $12 million

For State Construction Contracts under Chapter 10A, Small businesses with no more than 100 fulltime employees will be registered as a company with gross revenues that do not exceed either $1 million or the applicable annual revenue standards set forth in 13 CFR 121.201, whichever is higher. The business must be independently owned and operated, with management being responsible for both its daily and long term operation. Management owning at least 51% interest in the business. Must be incorporated or registered to do business in the State and have its principal place of business in New Jersey, defined when:

o 51% or more of its employees work in New Jersey supported by paid New Jersey unemployment taxes.

o 51% or more of its business operations/activities occur in New Jersey supported by income and/or business tax returns.

The business must be a sole proprietorship, partnership or corporation with 100 or fewer employees in full-time positions, not including:

o Seasonal and part-time employees employed for less than 90 days, if seasonal and casual part-time employment are common to that industry and

o Consultants employed under contracts not related to the goods and services, which are the subject of the specific contracts for which the business wants to be eligible as a small business.

NJSAVI (New Jersey Selective Assistance Vendor Information) is a database designed to assist small, women and/or minority businesses that wish to do business with the State of New Jersey and the private sector. The NJSAVI marketplace aids in matching buyers and vendors for private contracting opportunities.

To be registered as a Small Business Enterprise (SBE) for State of New Jersey Small Business contracts and Set-Aside program and be listed in the NJSAVI marketplace, please complete the New Jersey Small Business Vendor Registration Form enclosed.

Notarize and enclose the completed application with a non-refundable check or money order in the amount of $100 made payable to NJ Commerce and mail to:

New Jersey Commerce Office of Business Services 20 West State Street PO Box 820 Trenton NJ 08625-0820 (609) 777-0885

DO NOT SEND CASH

*Standard Industrial Classification (SIC) Codes can be obtained from **North American Industrial Classification System (NAICS) Codes can be obtained from

epcd/www/naics.html

To identify your commodity codes, visit the state treasury website at state.nj.us/treasury/purchase/commsrch.htm.

For construction craft codes, please see the attached list.

If you are seeking certification as a minority or woman-owned business enterprise and wish to obtain an application, call 1-888-239-1288, fax (609) 292-9145 or visit our website at

Bidder's List If your business enterprise is not registered with the New Jersey Purchase Bureau to receive State bid opportunities; call (609) 984-5396 or visit their website at state.nj.us/treasury/purchase to request a Bidder's Mailing List Application.

Should you have additional questions or require assistance in completing this form, it is recommended that you contact the

Small Business Development Center at (800) 432-1565.

11/03

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